Shock wave valvuloplasty with multiple balloons

ABSTRACT

Described herein are shock wave devices and methods for the treatment of calcified heart valves. One variation of a shock wave device includes three balloons that are each sized and shaped to fit within a concave portion of a valve cusp when inflated with a liquid and a shock wave source within each of the three balloons. Each balloon is separately and/or independently inflatable, and each shock wave source is separately and/or independently controllable. Methods of treating calcified heart valves using a shock wave device can include advancing a shock wave device having one or more balloons and a shock wave source in each of the balloons to contact a heart valve, inflating the one or more balloons with a liquid such that the balloon is seated within a concave portion of a valve cusp, and activating the shock wave source.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a continuation of U.S. patent application Ser. No.13/962,315, filed Aug. 8, 2013 which in turns claims the benefit of U.S.Provisional Application 61/681,068 filed on Aug. 8, 2012, both of whichare hereby incorporated by reference in their entirety.

BACKGROUND

Aortic valve stenosis results in the narrowing of the aortic valve.Aortic valve stenosis may be exacerbated by a congenital defect wherethe aortic valve has one leaflet (unicuspid) or two leaflets (bicuspid)instead of three leaflets. In many cases, the narrowing of the valve isthe result of aortic valve calcification, where calcified plaquesaccumulate on the leaflets and/or annulus of the aortic valve. Forexample, calcium plaques deposited on the cusps of the leaflets maystiffen the leaflets, thereby narrowing the valve opening andinterfering with efficient blood flow across the valve.

Although research is underway in the development of a replacement aorticvalve, one may prefer to soften the leaflets by cracking the calciumdeposits on the native valve instead of replacing it with an artificialvalve. Accordingly, improved methods of softening a calcified aorticvalve may be desirable.

BRIEF SUMMARY

Described herein are shock wave devices and methods for the treatment ofcalcified heart valves. The application of shock waves to a calcifiedregion of a valve may help to crack and/or break the calcium deposits,thereby softening and/or loosening and/or removing calcium deposits thatstiffen the mechanical properties of the valve. Softening and/orloosening and/or removing calcium deposits may allow the valve to regainat least a portion of its normal function. One variation of a device maycomprise at least one balloon that is sized and shaped to fit within aconcave portion of a valve cusp when inflated with a liquid and a shockwave source within the balloon. Optionally, a device for treating acalcified heart valve may comprise three balloons that are each sizedand shaped to fit within a concave portion of a valve cusp when inflatedwith a liquid and a shock wave source in each of the three balloons.Each balloon may be separately and/or independently inflatable, and eachshock wave source may be separately and/or independently controllable. Ashock wave device comprising three balloons and three shock wave sourcesmay be used for treating a tricuspid valve, such as the pulmonary valveand the aortic valve. Shock wave devices comprising one or two balloonsand one or two shock wave sources may be used for treating unicuspid,bicuspid and/or tricuspid valves.

Methods of treating calcified heart valves using a shock wave device maycomprise advancing a shock wave device having one or more balloons and ashock wave source in each of the balloons to contact a heart valve,inflating the one or more balloons with a liquid such that the balloonis seated within a concave portion of a valve cusp, and activating theshock wave source. The mechanical force of the shock waves may act tocrack and/or break calcium deposits located within the concave portionof the valve cusp. Inflation of the one or more balloons with a liquidmay act to automatically align and/or seat the balloon within theconcave portion of a valve cusp. Balloons and shock wave sources may beinflated and activated sequentially or simultaneously for the treatmentof all the cusps of a valve. Once the desired level of treatment hasbeen attained, the balloons may be deflated and withdrawn. Although thedescription below describes and depicts the treatment of an aorticvalve, it should be understood that similar devices and methods may beused to treat any heart valve, e.g., the pulmonary valve, mitral valve,tricuspid valve, as may be desirable.

Other devices and methods that may be used to crack and/or breakcalcified deposits in an aortic valve (e.g., as part of a valvuloplastyprocedure) are described in co-pending U.S. Pat. Pub. No. 2011/0295227filed Aug. 10, 2011, U.S. Pat. Pub. No. 2013/0116714 filed Nov. 8, 2011,U.S. patent application Ser. No. 13/957,276 filed Aug. 1, 2013, whichare hereby incorporated by reference in their entirety.

One variation of a device for the treatment of a heart valve (e.g., aheart valve having a plurality of cusps each having a concave portion)may comprise a first elongate body, a first balloon sealably enclosing aportion of the first elongate body, a first shock wave source coupled tothe first elongate body and enclosed within the first balloon, a secondelongate body, a second balloon sealably enclosing a portion of thesecond elongate body, and a second shock wave source coupled to thesecond elongate body and enclosed within the second balloon. The firstand second balloons may be independently inflatable with a liquid andmay be sized and shaped such that when inflated with the liquid, aportion of the balloons contact the valve. The portion of the balloonsthat contact the valve may approximate the size and shape of a concaveportion of a valvular cusp. The device may optionally comprise a thirdelongate body, a third balloon sealably enclosing a portion of the thirdelongate body, and a third shock wave source coupled to the thirdelongate body and enclosed within the third balloon, where the thirdballoon may be independently inflatable with a liquid. In somevariations, the shock wave source may be movable within their respectiveballoons. For example, the shock wave sources may be rotatable about alongitudinal axis of their respective elongate bodies, and/or may beadvanceable along a longitudinal axis of their respective elongatebodies.

Another variation of a device for treating a heart valve (e.g., a heartvalve having a plurality of cusps each having a concave portion) maycomprise a first elongate body, a first balloon sealably enclosing aportion of the first elongate body, a first shock wave source coupled tothe first elongate body and enclosed within the first balloon, a secondelongate body, a second balloon sealably enclosing a portion of thesecond elongate body, a second shock wave source coupled to the secondelongate body and enclosed within the second balloon, a third elongatebody, a third balloon sealably enclosing a portion of the third elongatebody, and a third shock wave source coupled to the third elongate bodyand enclosed within the third balloon. The first, second, and thirdballoons may be independently inflatable with a liquid and may be sizedand shaped such that when inflated with the liquid, a portion of theballoons contact the valve. The portion of the balloons that contact thevalve may approximate the size and shape of a concave portion of avalvular cusp.

Any of the devices described herein may further comprise at least onestand-off on the external surface of at least one of the balloons. Insome variations, the at least one stand-off may comprise a curved ridgealong a segment of the external surface of the balloon. Optionally, theelongate bodies of any of the devices described herein may comprise acompressed configuration and an expanded configuration, wherein in thecompressed configuration, a distal portion of the elongate bodies may berelatively straight and in the expanded configuration, the distalportion of the elongate bodies may be curved.

Also described herein are methods for applying shock waves to an aorticvalve. One variation of a method may comprise introducing shock wavedevice into a patient's vasculature, where the shock wave device maycomprise a first elongate body, a first balloon sealably enclosing aportion of the first elongate body, a first shock wave source coupled tothe first elongate body and enclosed within the first balloon, a secondelongate body, a second balloon sealably enclosing a portion of thesecond elongate body, and a second shock wave source coupled to thesecond elongate body and enclosed within the second balloon, advancingthe shock wave device within the vasculature to contact an aortic valvehaving a first cusp and a second cusp, inflating the first balloon witha liquid, where inflating the first balloon causes the first balloon tobe aligned within a concave portion of the first cusp, and activatingthe first shock wave source to apply a shock wave to the first cusp. Thefirst and second balloons may be independently inflatable with a liquid.The shock wave device may be advanced in a retrograde direction in thevasculature. In some variations, the method may further compriseinflating the second balloon with a liquid, where inflating the secondballoon causes the second balloon to be aligned within a concave portionof the second cusp, confirming that the first balloon and the secondballoon are each aligned within the concave portions of the first andsecond cusp respectively, and deflating the second balloon beforeactivating the first shock wave source.

Optionally, some methods may comprise deflating the first balloon afteractivating the first shock wave source, inflating the second balloonwith a liquid, where inflating the second balloon causes the secondballoon to be aligned within a concave portion of the second cusp, andactivating the second shock wave source to apply a shock wave to thesecond cusp. Alternatively or additionally, a method may compriseinflating the second balloon with a liquid, where inflating the secondballoon causes the second balloon to be aligned within a concave portionof the second cusp, confirming that the first balloon and the secondballoon are each aligned within the concave portions of the first andsecond cusp respectively, and activating the second shock wave source toapply a shock wave to the second cusp. In some variations, the first andsecond shock wave sources may be activated substantially simultaneously.These methods may be used to apply shock waves to a first cusp and asecond cusp, where the first cusp is a right semilunar cusp and thesecond cusp is a posterior semilunar cusp, or the first cusp is a leftsemilunar cusp and the second cusp is a posterior semilunar cusp, or thefirst cusp is a right semilunar cusp and the second cusp is a leftsemilunar cusp. Shock waves may be applied to the first and second cuspssimultaneously or sequentially. Optionally, the shock wave devices usedin any of these methods may comprise a third elongate body, a thirdballoon sealably enclosing a portion of the third elongate body, and athird shock wave source coupled to the third elongate body and enclosedwithin the third balloon, where the third balloon is independentlyinflatable with a liquid.

Another variation of a method for applying shock waves to an aorticvalve may comprise introducing shock wave device into a patient'svasculature, the shock wave device comprising a first elongate body, afirst balloon sealably enclosing a portion of the first elongate body, afirst shock wave source coupled to the first elongate body and enclosedwithin the first balloon, advancing the shock wave device within thevasculature to contact an aortic valve having a first cusp and a secondcusp, inflating the first balloon with a liquid, where inflating thefirst balloon causes the first balloon to be aligned within a concaveportion of only the first cusp, and treating the first cusp byactivating the first shock wave source to apply a shock wave to thefirst cusp. The first and second balloons may be independentlyinflatable with a liquid. The shock wave device may be advanced in aretrograde direction in the vasculature. The method may further comprisedeflating the first balloon after treating the first cusp, moving thefirst balloon to the second cusp, inflating the first balloon with aliquid, where inflating the first balloon causes the first balloon to bealigned within a concave portion of only the second cusp, and treatingthe second cusp by activating the first shock wave source to apply ashock wave to the second cusp. In some variations, the shock wave devicemay further comprise a second elongate body, a second balloon sealablyenclosing a portion of the second elongate body, a second shock wavesource coupled to the second elongate body and enclosed within thesecond balloon. The second balloon may be inflatable with a liquidindependently from the first balloon. A method using a shock wave devicecomprising two balloons may optionally comprise deflating the firstballoon after treating the first cusp, inflating the second balloon witha liquid, where inflating the second balloon causes the second balloonto be aligned within a concave portion of only the second cusp, andtreating the second cusp by activating the second shock wave source toapply a shock wave to the second cusp. Optionally, a shock wave deviceused in any of the methods described herein may further comprise atleast one stand-off on the external surface of at least one of theballoons such that when the at least one balloon is inflated with aliquid and is located with a concave portion of a cusp, the balloon doesnot obstruct blood flow to a coronary artery.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1A depicts a cutaway view of the heart (sectioned along the planeindicated in the inset. FIG. 1B depicts a top view of the heart, asviewed from the base with the atria removed. FIG. 1C is a view of theaortic valve that has been cut anteriorly between the left cusp and theright cusp and splayed open. FIG. 1D is a top view of a calcified aorticvalve. FIG. 1E is a top view of a bicuspid aortic valve.

FIG. 2A schematically depicts one variation of a shock wave device forthe treatment of calcified heart valves. FIG. 2B depicts a distalportion of the shock wave device of FIG. 2A. FIG. 2C depicts a proximalview of the distal portion of FIG. 2B. FIG. 2D is a side view of thedistal portion of FIG. 2B. FIG. 2E is a top view of the device of FIGS.2A-2D deployed within a cusp of an aortic valve. FIG. 2F is a side viewof the device of FIGS. 2A-2D deployed within a cusp of an aortic valve.

FIG. 3 schematically depicts one variation of a shock wave device forthe treatment of calcified heart valves comprising three balloons andthree shock wave sources within the balloon.

FIGS. 4A-4C depict one variation of method for treating a calcifiedheart valve using a shock wave device. FIG. 4D depicts a schematic topview of a shock wave device deployed in an aortic valve.

FIGS. 5A-5C are flowchart representations of additional variations ofmethods for treating a calcified heart valve using a shock wave device.

DETAILED DESCRIPTION

FIGS. 1A-1C depict various views of the valves of the heart. FIG. 1A isa cross-sectional view of a heart 100 taken along the plane indicated bythe inset. The aortic valve 101 comprises a left semilunar leaflet orcusp 102, a right semilunar leaflet or cusp 104 and a posteriorsemilunar leaflet or cusp 106. Each cusp has a free margin, whicharticulates with the free margins of the other cusps when the valvecloses, and an attached margin that attaches the cusp in a semilunarfashion to the aortic wall. When the aortic valve is closed, theventricular side of the cusps may have a convex surface and the aorticside of the cusps may have a concave surface. The concave portion ofeach of the cusps may be bordered by the concave surface of the cusp,the free margin of the cusp, the attached margin of the cusp, and mayalso include a portion of the valve wall. Alternatively or additionally,the concave portion of each of the cusps may include the aortic sinusassociated with each cusp. FIG. 1B depicts a top view (viewed from thebase with the atria removed) of the aortic valve 101 in a closedconfiguration, showing the concave portion of each of the left semilunarcusp 102, right semilunar cusp 104 and posterior semilunar cusp 106. Asillustrated there, the free margins 108 of each of the cusps articulatewith each other to prevent the blood from passing through the valve whenclosed. The concave portions 110, 112, 114 of the left, right, andposterior cusps respectively are also shown in FIG. 1B. As depicted inFIG. 1C, the concave portions of each cusp may also include a portion ofthe aortic sinus 111, 113, 115 associated with that cusp. The concaveportion 110 or aortic sinus 111 of the left cusp 102 may comprise anopening 116 to the left coronary artery 118, and the concave portion 112or aortic sinus 113 of the right cusp 104 may comprise an opening 120 tothe right coronary artery 122. The concave portion 114 or aortic sinus115 of the posterior cusp may not have any coronary artery openings.

FIGS. 1D and 1E depict aortic valves that may be susceptible tostenosis. As shown in FIG. 1D, calcified plaques or deposits mayaccumulate on the aortic side of the leaflets, for example, along theconcave portion of the cusp, as indicated by the dashed areas 130, 132.Calcium deposits on the aortic valve leaflets and walls may stiffen thevalve considerably, and compromise its ability to open and closeeffectively. Nodular deposits 132 may accumulate along the free marginsof the leaflets, and sheets of deposits 130 may accumulate within theconcave portion of the leaflets (e.g., along the aortic side of theleaflets). Nodular deposits 132 may act to adhere the free margins ofthe cusps to each other, which would reduce the size of the valveopening. Sheet-like deposits along the aortic surface of the cusp (e.g.,the concave portion and/or aortic sinus) may act to stiffen the cusp andinterfere with its ability to open and close. Some patients may have abicuspid aortic valve, which is a congenital condition that may resultin an aortic valve having two leaflets instead of three leaflets. FIG.1E depicts a bicuspid aortic valve, the function of which may beparticularly compromised by the accumulation of calcified deposits alongthe free margins and/or concave portions of the two leaflets. Cracking,breaking and/or removing these deposits may help the aortic valve toregain its normal function. The shock wave devices and methods describedherein may be delivered to the concave portions of the aortic valveleaflets and/or aortic sinuses in order to crack, break, soften, removeand/or otherwise reduce the effect of calcium deposits on the functionof the valve.

A shock wave device that may be used to treat calcified regions of theaortic valve may comprise an elongate body, a balloon that sealablyencloses a distal portion of the elongate body, and a shock wave sourcecoupled to the elongate body and enclosed within the balloon. Theballoon may be filled with a liquid, and when the shock wave source isactivated, shock waves may propagate through the liquid and apply amechanical force on the wall of the balloon. By placing the balloon wallin contact with a calcified tissue region (e.g., concave portion of acusp and/or aortic sinus), the mechanical force from the shock wave maybe transferred to the calcium deposit, thereby cracking and/or breakingthe deposit. The closer the contact between the balloon wall and thecalcified tissue, the more efficient the transfer of mechanical energyfrom the shock wave device to the calcium deposits. Furthermore, thecloser the shock wave source within the balloon is to the calcifiedtissue, the greater the magnitude of mechanical force that may bedelivered to the calcium deposit. The size and shape of the balloon maybe selected so that when the balloon is inflated with a liquid, at leasta portion of the balloon is capable of being seated and/or positionedwithin the concave portion and/or aortic sinus of a cusp. For example,the balloon may be sized and shaped such that when the balloon isinflated in the proximity of an aortic valve cusp, the balloonautomatically seats and/or positions itself within the concave portionand/or sinus of the cusp. The size and shape of the balloon may betailored to the unique geometry of a patient's aortic valve (e.g., tomatch the geometry of the aortic cusps and/or aortic sinus). Forexample, the diameter of a balloon may be from about 5 mm to about 15mm, which may correspond to the size of a concave portion of a cusp.Balloons may be spherical, but may also have other shapes that may helpto position it in a concave portion of a valve (e.g., tetrahedron withrounded and/or sharp corners or edges, pyramid with rounded and/or sharpcorners or edges, square-circle-triangle block, etc.). The balloons maybe made of a non-compliant material and may be molded to mimic the shapeof a coronary sinus of the valve.

Optionally, the elongate body of the shock wave device may have shapememory such that it may be advanced through the vasculature in arelative straight configuration (e.g., constrained by a guide tube) andwhen deployed, may assume a curved or bent configuration that may helpseat the balloon within (or in close proximity to) the aortic surface ofthe cusp prior to or during inflation. For example, the elongate bodymay be biased to assume a bent and/or an expanded configuration whendeployed at or near a valve cusp, which may help the device toself-align the balloons within the concave portion and/or sinus of thecusp. The balloon may be bonded to a distal portion of the elongatebody, which may provide a fluid path to fill the balloon with saline orsaline/contrast mixture. The elongate body may be formed of a compliantmaterial to absorb the volume changes that may be caused by the steambubble that may arise from shock waves generated in the balloon. In somevariations, the shock wave source enclosed within the balloon may bemovable within the balloon, such that shock waves can be initiated fromany location within the balloon to apply mechanical forces to a targetedregion of tissue. For example, the shock wave source may be advanced orretracted longitudinally along the axis of the elongate body (e.g., in aproximal to distal direction), rotated (e.g., around the axis of theelongate body), and/or bent at an angle with respect to the axis of theelongate body (e.g., the shock wave source may be located at a distaltip of a steerable catheter and/or a catheter with shape memory suchthat it assumes a bent configuration when unconstrained).

Optionally, the balloon of a shock wave device may comprise one or morestand-off structures on its external surface. Examples of stand-offstructures may include, but are not limited to, ridges, bumps,protrusions, struts, etc. These stand-off structures may help to keep aninflated balloon that is seated within the concave portion and/or sinusof a cusp from blocking any arterial openings that may be in the sinus.For example, having one or more stand-off structures on balloons thathave been inflated in the left cusp or right cusp may help to preventthe balloon from blocking the openings of the left or right coronaryarteries. Maintaining patency of the coronary artery openings may allowcontinuous perfusion to the heart while the shock wave procedure isbeing performed, which may help reduce the occurrence of cardiacischemia during the procedure.

A shock wave device that comprises a single elongate body, balloon andshock wave source may be used to treat one cusp of a valve at a time(i.e., after treatment of a first cusp, the device may be repositionedand seated in a concave portion of a second cusp to treat the secondcusp, and so on). In some variations, a shock wave device may comprisetwo or three sets of elongate bodies, balloons and shock wave sources,which may allow for the treatment of multiple cusps simultaneously, aswell as for the treatment of bicuspid aortic valves. Additional balloonsmay also help to seat and/or position the shock wave device within theconcave portion of the valve cusps more efficiently and/or precisely.While certain features and structures are described for particularvariations of shock wave devices, it should be understood that thosefeatures and structures may also be incorporated into other variationsof shock wave devices.

One variation of a shock wave device that may be used to crack and/orbreak calcified deposits located in the aortic valve is depicted inFIGS. 2A-2D. Shock wave device 200 may comprise an elongate body 202, aballoon 204 sealably enclosing a portion of the elongate body, and ashock wave source 206 within the balloon. The balloon 204 may be locatedat the distal end of the elongate body 202, and may be inflatable by theintroduction of fluid (e.g., liquid) at the proximal end of the elongatebody (e.g., via a port 210, which may be a luer lock connector of aproximal handle portion 211). Alternatively, the elongate body may havea separate fluid lumen for inflating the balloon. The balloon 204 maycomprise two elongated protrusions or ridges 212 a, 212 b along itsexternal surface, which may act as stand-offs to prevent occlusion ofcoronary artery openings when the balloon is inflated in a sinus of acusp. The shock wave source 206 may comprise a shaft 208 and at leastone electrode pair 207 located at the distal end of the shaft which areconnected to a high voltage power supply. The shock wave source 206 maybe advanced along the longitudinal axis of the elongate body 202 (e.g.,into and out of the elongate body 202, according to arrows 201), and/ormay be rotated around the longitudinal axis of the elongate body 202(e.g., according to arrows 203, and/or may be bent at an angle) byturning and/or pushing and/or pulling a knob 213 of the proximal handleportion 211. The shaft 208 may be a steerable shaft where an actuatingmechanism (e.g., pull wires) may be used to cause the shaft to bend,and/or may have shape memory, where the shaft is pre-shaped to have abend 205 when in an unconstrained configuration. While the shock wavesource 206 depicted in the drawings comprises an electrode pair 207 in acoaxial configuration at the distal tip of the shaft 208, it should beunderstood that there may be more than one electrode pair along theshaft, and that the electrode pair may have a variety of configurations.In some variations, the shock wave electrode pair may be located along aside of the shaft 208. Examples of shock wave electrode configurationsare described in U.S. Pub. No. 2009/0312768 filed Jun. 11, 2009 and U.S.application Ser. No. 13/831,543 filed Mar. 14, 2013, which are bothhereby incorporated by reference in their entirety. Alternatively oradditionally, a shock wave source may comprise optical fibers or lasersthat are configured to generate shock waves.

FIGS. 2C and 2D depict top and side views of the balloon 204, ridges 212a and 212 b, and shock wave source 206. FIG. 2E depicts a top view andFIG. 2F depicts a side view of the shock wave device deployed at theaortic valve 230 (only the left cusp 232 of the valve is depicted). Asseen from the side view in FIG. 2F, the balloon 204 is inflated with aliquid and is seated within a concave portion 234 of the left cusp 232.Inflation of the balloon 204 and/or shape memory of the elongate body202 may help the balloon 204 to self-align into the concave portion 234of the left cusp 232. The balloon may be seated within the concaveportion 234 of the cusp such that the balloon is bordered by the valvewall 240 (e.g., wall of the sinus), the concave surface 242 (on theaortic side) of the cusp, and the free edge 244 of the cusp. When seatedwithin the concave portion of a cusp, the balloon may be pressed againstthe valve wall 240 such that the balloon does not cross the free edge ofthe cusp and intersect with the free edge of another cusp (e.g., theballoon does not span across two cusps, and/or the balloon does notextend within the aortic valve orifice). As seen from the top view inFIG. 2E, the balloon is seated within the concave portion 234 such thatit is bordered by the valve wall 240 and the free edge 244 of the cusp.The balloon may also comprise ridges 212 a, 212 b help to ensure thatthe balloon does not obstruct the opening 236 of the left coronaryartery. While two ridges are depicted, it should be understood thatthere may be any number of ridges or protrusions as may be desirable forensuring that there is a space between the balloon wall and the aorticwall (e.g., 1, 2, 3, 4, 5, 6, 8, 10, 12, 15, etc. protrusions orridges).

A shock wave device for the treatment of calcified heart valves maycomprise additional sets of elongate bodies, balloons, and shock wavedevices. Some variations may have two elongate bodies, two balloons(each of which sealably encloses a portion of one of the two elongatebodies), and two shock wave sources (one in each of the two balloons).Other variations may have three sets of elongate bodies, balloons, andshock wave devices, such as the shock wave device 300 depicted in FIG.3. The shock wave device 300 may comprise a first elongate body 302, afirst balloon 304 sealably enclosing a portion of the first elongatebody, a first shock wave source 306, a second elongate body 312, asecond balloon 314 sealably enclosing a portion of the second elongatebody, a second shock wave source 316, a third elongate body 322, a thirdballoon 324 sealably enclosing a portion of the third elongate body, anda third shock wave source 326. The shock wave sources may be connectedat a proximal end to a high voltage pulse generator 301, where apositive terminal of each shock wave source may be connected to apositive port of the pulse generator and a negative terminal of eachshock wave source may be connected to a common ground terminal. Thefirst, second and third balloons may be separately and/or independentlyinflatable (e.g., have separate inflation lumens). In some variations,the first, second and third balloons may be inflated one at a time(e.g., sequentially), and/or two at a time. All the balloons of a shockwave device may also be inflated simultaneously. For example, asdepicted in FIG. 3, the three elongate bodies 302, 312, 322 connect to acommon shaft 303, and share a common inflation lumen 341 of a proximalhandle 340. The first, second and third shock wave sources may beseparately and/or independently activated. Each of the shock wavesources 306, 316, 326 may comprise an insulating shaft 307, 317, 327which may house the wiring between the high voltage pulse generator andthe shock wave electrodes 305, 315, 325 at the distal end of the shaft.The pulse generator may be controlled by a controller that is programmedto provide voltage pulses to each of the shock wave sources sequentially(e.g., one at a time) or simultaneously (e.g., two at a time, three at atime). Each of the three balloons and corresponding shock wave sourcesmay be inflated, actuated, and activated by three separate proximalhandle portions, each similar to the handle portion described anddepicted in FIG. 2A. Additional fluid ports and/or actuating mechanismfor moving the shock wave source may be included at a proximal portionas may be desirable.

The insulating shafts 307, 317, 327 and/or the elongate bodies 302, 312,322 may have be biased to expand when unconstrained (e.g., by anovertube or catheter). In some variations, the shafts and/or elongatebodies may be spring-biased, and/or may have shape memory such that whenunconstrained, they assume a bent and/or expanded configuration.Expansion and/or bending of the shafts and/or elongate bodies may helpto position the balloons along the aortic valve such that when inflated,the balloons may self-align with the cusps and may be seated and/orpositioned within a concave portion of the cusp and/or the sinus of thecusp.

FIGS. 4A-4C depict one variation of a method for treating a calcifiedheart valve (e.g., an aortic valve) using a shock wave device. Althoughthe method depicted there uses a shock wave device comprising twoballoons, it should be understood that this method may be performedusing any of the shock wave devices disclosed herein (e.g., shock wavedevices having one balloon or three balloons). FIG. 4A depicts across-sectional schematic view of an aortic valve 400 with the left cusp402 and the right cusp 404 (the posterior cusp is not shown for the sakeof simplicity). The concave portion 403 of the left cusp 402 includesthe left sinus and the opening 407 of the left coronary artery 406. Theconcave portion 405 of the right cusp 404 includes the right sinus andthe opening 409 of the right coronary artery 408. A guide catheter 410may be introduced into the vasculature and advanced in a retrogradedirection (e.g., via a femoral artery) to the aortic valve 400. Theguide catheter 410 (as well as any of components of the shock wavedevice) may comprise a radiopaque band or marker so that the location ofthe catheter may be determined using fluoroscopy. Alternatively oradditionally, the location of the catheter and/or any shock wave devicesmay be determined using ultrasound. The guide catheter 410 may bepositioned just downstream (e.g., above) from the cusps. A shock wavedevice 412 may then be advanced through the guide catheter 410 to theaortic valve. The shock wave device 412 may comprise a first elongatebody 414, a first balloon 416 sealably attached to the distal end of thefirst elongate body 414, a first shock wave source 418 enclosed withinthe first balloon 416, a second elongate body 424, a second balloon 426sealably attached to the distal end of the second elongate body 424, anda second shock wave source 428 enclosed within the second balloon 426.Alternatively, the shock wave device may be any of the shock wavedevices described herein. The first and second elongate bodies and/orthe shafts of the first and second shock wave sources may be biased suchthat they bend at an angle and/or expand when unconstrained. The shockwave device 412 may be advanced through the guide catheter 410 in acompressed configuration, where the first and second elongate bodiesand/or the shafts of the first and second shock wave sources may begenerally aligned with the longitudinal axis of the guide catheter 410.

As shown in FIG. 4B, advancing the shock wave device 412 distally beyondthe distal end of the guide catheter may allow the first and secondelongate bodies and/or the shafts of the first and second shock wavesources to assume their bent configuration, thereby expanding the shockwave device such that the first and second balloons 416, 426 (deflatedduring delivery) contact the aortic valve wall. The expansion of theshock wave device may at least partially align the balloons with theconcave portions 403, 405 of the left and right cusps, and help toposition the balloons away from the valve orifice and along the valvewall. Next, as depicted in FIG. 4C, one or both of the balloons may beinflated with a liquid, which may cause the balloons to self-alignwithin the concave portions of the cusps, and may help reduce the amountof maneuvering of the shock wave device needed to position the balloonswithin the concave portions and/or sinuses of the cusps. In somevariations, only one balloon may be inflated at a time, or two balloonsmay be inflated simultaneously. Inflating fewer balloons than the numberof cusps of a valve may allow blood to flow through at least a portionof the valve, which may help to reduce the risk of an ischemic incidentduring the procedure.

The balloons may comprise one or more ridges 417, 427 (not shown inFIGS. 4A and 4B, but shown in FIG. 4C) that may act to maintain a spacebetween the inflated balloon and the valve wall (e.g., such that theinflated balloon does not block the artery openings 407, 409). This mayallow for continuous perfusion through the valve and around the cusps,as well as blood flow into the left and right coronary arteries 406, 408through the artery openings 407, 409. FIG. 4D depicts a top view of ashock wave device comprising three balloons 433, 434, 435 (inflated witha fluid) enclosing three shock wave sources 436, 437, 438 that may bedeployed to an aortic valve 440. Each balloon may comprise at least tworidges 430 that help to maintain a space between the balloon and thevalve wall, which may help to prevent obstruction of the openings to thecoronary arteries 432, 434. As seen there, each of the three balloons isseated within a concave portion and/or sinus 441, 442, 443 of each ofthe cusps of the aortic valve. The location of the balloons may bedetermined based on fluoroscopy and/or ultrasound, as previouslyindicated. For example, a portion of the ridges 417, 427 may be made ofa radiopaque material that may be visualized using fluoroscopy. Aradiopaque ridge may allow a practitioner to confirm that the balloonsare seated within a concave portion and/or sinus of the cusps, as wellas to confirm that the ridges themselves are not obstructing theopenings to the coronary arteries and/or confirm that the balloons arenot inserted through and/or obstructing the valve orifice. In somevariations, the bias of the elongate body and/or shock wave shaft, alongwith inflation of the balloons may help to self-align the balloons withthe concave portions of the cusps and/or automatically seat the balloonswithin the concave portions of the cusps. Such bias may also help toensure that none of the balloons obstruct and/or extend through thevalve orifice, but are instead pressed along the wall of the valve.

After a practitioner confirms that the balloons are located in thedesired position, one or more of the shock wave sources may be activatedto produce shock waves. The location of the balloons and/or shock wavedevices may be monitored throughout the treatment procedure as needed toconfirm that the balloons are in close proximity to and/or in contactwith calcified regions of the valve. The mechanical force from the shockwaves may propagate through the liquid to apply a mechanical force onany calcified deposit along the surface of the cusp. A plurality ofshock waves may be applied to the cusps and/or other valve structures.In some variations, the shock wave devices may be moved within a balloonso that the mechanical forces from the shock waves may be focused ondifferent areas of a cusp without moving the balloon. For example, shockwave treatment of a calcified cusp may comprise initiating shock wavesfrom the shock wave source at a first location (which may, for example,apply mechanical force to calcified deposits along the attached edge ofthe cusp), then moving the shock wave source in the balloon to a secondlocation, and then initiating shock waves from the shock wave source ata second location (which may, for example, focus the mechanical force tocalcified deposits along the free edge of the cusp). Efficacy of thetreatment may be subsequently evaluated based on imaging techniques(e.g., fluoroscopy and/or ultrasound) and/or physiological parameters.Examples of techniques that may be used to evaluate the efficacy of thetreatment may include, but are not limited to, visual observation byultrasound of leaflet activity (e.g., leaflet opening and closing) whenthe balloons are deflated or withdrawn from the valve, measuringejection fraction, Duke Activity Status Index (DASI), peak velocity,peak gradient, valve effective orifice area, Doppler velocity, etc.

Optionally, after a desired amount of the calcium deposits have beencracked and/or loosened, and/or the leaflets of the valve have beensoftened, a transcatheter aortic valve implantation (TAVI) procedure maybe performed. Cracking and/or breaking the calcium deposits on an aorticvalve may help to improve the outcome of a subsequent TAVI procedure.Described below are additional methods that may comprise one or more ofthe steps described above.

In some methods, a single cusp of a valve may be treated at a time,while in other methods, two or more cusps of a valve may be treatedsimultaneously. FIGS. 5A-5C depicts flowchart diagrams representingvariations of methods for cracking and/or breaking calcified depositsthat may be located along the surface of a cusp on the aorta side. Inone variation, such as is depicted in FIG. 5A, a shock wave device witha single balloon and shock wave source within the balloon may be used totreat a first calcified cusp (e.g., the right cusp), then a secondcalcified cusp (e.g., the left cusp) and then a calcified third cusp(e.g., the posterior cusp) sequentially. In this method 500, a guidecatheter is advanced in a retrograde direction to the aortic valve (502)and the shock wave device is advanced through the guide catheter (504),as previously described. A balloon is deployed to a first cusp (506),where it is inflated with a fluid (508), and its position within theconcave portion and/or sinus of the cusp is confirmed (510). The shockwave source within the balloon may be activated (512) and the mechanicalforce from plurality of shock waves may act to crack and/or break thecalcium deposits within the first cusp. Once that first cusp has beensatisfactorily treated, the shock wave device may be moved (e.g.,rotated), such that the balloon is moved from the first cusp to theconcave portion of a second cusp (step 514) the balloon may or may notbe deflated prior to moving it to the second cup). After the position ofthe balloon in the concave portion of the second cusp has beenconfirmed, the shock wave source within the balloon may be activated(516). The process may then be repeated for the third cusp (steps518-520).

In another variation, as shown in FIG. 5B, a shock wave device with twoballoons and two shock wave sources may be used to sequentially treatone calcified cusp at a time. In such a method 530, the shock wavedevice is advanced to the aortic valve, as previously described (steps532, 534), and then both balloons may be deployed (536) and inflatedsimultaneously to seat the balloons within the concave portion of thecusps (538). Optionally, a shock wave device with three balloons andthree shock wave sources may have all three balloons inflatedsimultaneously. Once the balloon positions have been confirmed (step540, e.g., the balloons are aligned with the concave portions of thecusps, and/or are located within the cusps), a first balloon in a firstcusp may be deflated while a second balloon in a second cusp may remaininflated (542). Where a three-balloon shock wave device is used, a thirdballoon in a third cusp may be deflated. The shock wave source in thesecond balloon may be activated to crack and/or break the calcifieddeposits within the second cusp (544). Inflating more than one balloonmay be helpful to position and/or seat the balloons within the concaveportion of a cusp. Deflating all but one of the balloons duringtreatment may help to reduce the obstruction of blood flow through thevalve during a procedure, thus extending the time available to performthe whole procedure. After the second cusp has been treated, the secondballoon may be deflated and the first balloon inflated for treating thefirst cusp (546). The shock wave source in the first balloon may beactivated to crack and/or break the calcified deposits within the firstcusp (548). These steps may be repeated as may be desirable (e.g., forthe treatment of a third cusp, and/or repeated treatment of the firstand second cusps).

FIG. 5C depicts an example of a method 550 for treating two (or three)calcified cusps simultaneously. A shock wave device comprising twoballoons and two corresponding shock wave sources may be advanced to theaortic valve, as described previously (steps 552, 554). In somevariations, a three-balloon shock wave device instead of a two-balloonshock wave device. Two balloons may be deployed (556) inflatedsimultaneously (558) to seat the balloons within the concave portion ofthe cusps (with a three-balloon device, the third balloon may optionallybe inflated). Once the position of the balloons within the concaveportions of the cusp and in desired contact with the calcified depositshave been confirmed (560), the two shock wave sources within the twoballoons may be activated simultaneously to apply mechanical forces tothe calcified deposits in both cusps (562). After the two cusps havebeen treated, at least one of the balloons may be deflated (564). Thethird cusp may be treated by rotating the shock wave device so that aballoon is aligned with and/or seated within the third cusp (e.g., inthe case of a two-balloon shock wave system), inflating the balloonwithin the third cusp (566), confirming its location within the thirdcusp (568) and activating the shock wave source within that balloon totreat the third cusp (570). Where a three-balloon shock wave device isused, the device need not be re-positioned to treat the third cusp, andinstead, the third balloon may be inflated (566), to seat it within thethird cusp and the third shock wave source may be activated (570).Confirming the position of the third balloon within the third cusp maybe optional. Optionally, when the third balloon is inflated, one or bothof the other two balloons may be deflated. In some variations, threeballoons may be inflated simultaneously to treat three cuspssimultaneously. While a three balloon system may be capable of inflatingmore than one balloon to treat more than one cusp at a time, in somevariations, a three balloon system may be used to treat a single cusp ata time (i.e., inflating only one balloon at a time). Sequentialinflation of a single balloon at a time may be desirable in cases wherea practitioner desires to reduce the level of obstruction of the aorticvalve orifice during treatment.

In methods where two calcified cusps are treated simultaneously, one ofthe cusps may have a coronary artery opening in its sinus (e.g., a rightor left cusp) while the other cusp may not have a coronary arteryopening in its sinus (e.g., the posterior cusp). Leaving the third cusp(e.g., the left or right cusp) unobstructed by a balloon while the othertwo cusps are undergoing treatment may help ensure a consistent flow ofblood to the coronary artery associated with that cusp, as well as tokeep a portion of the valve orifice open during treatment. For example,balloons may be inflated in the left cusp and the posterior(non-coronary) cusp to treat those cusps, while the balloon alignedand/or positioned within the concave portion of the right cusp mayremain deflated. After the left cusp has been treated, its correspondingballoon may be deflated and the balloon in the right cusp may beinflated. The shock wave source in the balloon in the right cusp maythen be activated to treat the right cusp. Optionally, the balloonwithin the posterior cusp may remain inflated for continued treatment(e.g., simultaneously with treatment of the right cusp), or the balloonmay be deflated. These steps may be repeated as desired. In othervariations, the right and left cusps may be treated simultaneously,where the balloons seated in those cusps are inflated at the same time.As described previously, balloons may have one or more stand-offstructures (e.g., ridges and the like) which may help to maintain aspace between the balloon and the wall of the coronary sinus where theopenings of the coronary arteries are located. Maintaining this spacemay allow blood to continue to flow to the coronary arteries and reducethe degree to which the inflated balloons obstruct the openings of thecoronary arteries. After the left and right cusps have been treated, oneor both of the balloons in the right and left cusps may be deflated andthe balloon in the posterior cusp may be inflated. In still othervariations, balloons may be seated and inflated in the three cusps ofthe aortic valve so that the three cusps may be treated simultaneously.

The methods and devices described above may also be used for thetreatment of bicuspid aortic valves. For example, a method for treatinga calcified bicuspid aortic valve may comprise inflating only oneballoon of a shock wave device to treat only one cusp at a time. Inother variations, methods for treating a calcified bicuspid aortic valvemay comprise inflating two balloons at a time for simultaneous shockwave treatment of both of the cusps. Optionally, a TAVI procedure may beperformed after treating the valve with the shock wave device.

While this invention has been particularly shown and described withreferences to embodiments thereof, it will be understood by thoseskilled in the art that various changes in form and details may be madetherein without departing from the scope of the invention. For all ofthe embodiments described above, the steps of the methods need not beperformed sequentially.

What is claimed:
 1. A device for treatment of an aortic valve having at least first and second cusps, each cusp having a free end, said device comprising: a catheter; a first elongate member translatable within the catheter, with a distal end of the first elongate member housing a first shock wave source, with the distal end of the first elongate member being configured to fit within a concave portion of the first cusp facing the aorta and does not extend beyond the free edge of the first cusp to permit blood to flow through the aortic valve; and a second elongate member translatable within the catheter, with a distal end of the second elongate member housing a second shock wave source, with the distal end of the second elongate member being configured to fit within a concave portion of the second cusp facing the aorta and does not extend beyond the free edge of the second cusp to permit blood to flow through the aortic valve.
 2. A device as recited in claim 1 for treatment of a valve having first, second and third cusps each cusp having a free end, said device further including a third elongate member translatable within the catheter, with a distal end of the third elongate member housing a third shock wave source, with the distal end of the third elongate member being configured to fit within a concave portion of the third cusp facing the aorta and does not extend beyond the free edge of the third cusp to permit blood to flow through the aortic valve.
 3. A device as recited in claim 1 wherein the distal end of the first elongate member includes an inflatable balloon surrounding the first shock wave source and wherein distal end of the second elongate member includes an inflatable balloon surround the second shock wave source.
 4. A device as recited in claim 1 wherein the first and second shock sources are movable within the respective elongate member. 